complaint·October 29, 2024

On 10/18/2023, LPA Dolores entered into R1’s bedroom. R1’s bed was removed as R1 passed away early morning of 10/18/2023. LPA observed an alert button on the wall that was placed above the night stand. Based on interview with staff (S1) and (S2), R1’s bed was located to the right of the night stand. LPA observed that the alert button may not be of arms reach if a person is laying down in bed. The alert button did not contain a pull cord. Based on interview with S2, S2 stated that R1 was not able to reach the button. LPA Dolores pressed the alert button above the night stand at 2:34PM and there was no response from staff at 2:45PM (11 minutes after the alert button was pressed). At 2:39PM, LPA entered room #2 located right next to R1’s room. At 2:39PM, LPA pressed the alert button next to the bed. 2:41PM, S1 pushed the alert button in the bathroom. 2:42PM, LPA Dolores pressed the alert button next to the bed a second time. At 2:45PM, there was no response from staff. Based on record review, R1’s alerts were not responded to on 10/07/2023, 10/08/2023, 10/10/2023, 10/12/2023, 10/15/2023, 10/17/2023, and 10/18/2023 (7 different occasions). The Department has investigated the above allegation. Based on record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with General Manager, Billy Mitchell and a copy of the report and appeal rights was provided. PAGE 2 OF 2. Based on record review, R1 was under hospice care. On 10/10/2023, R1’s family member called 911 and the paramedics and police arrived to the facility. Based on interview with S2, R1’s family member called 911 because R1 was not feeling well. The paramedics arrived to the facility and assessed R1 and R1 verbalized that he/she wanted to stay and did not want to go to the hospital. S2 states the facility was instructed by R1’s hospice team to call 911 if the resident sustains an injury like a fall. The review of R1’s records indicates that R1 was a DNR and on comfort focused treatment. The Department has investigated the above allegation. Based on interview and record review the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager, Billy Mitchell and a copy of the report was provided. PAGE 2 OF 2. Based on record review, the facility obtained both POA documents from two of R1’s family members. The first POA document is dated in 2020 and the second POA document is dated in 2023. Based on interview, S1 and S2 states they received two POA documents from both family members. The second POA document dated 2023 was when R1 already had dementia. S2 states they were using the initial POA documents while pending further clarification from the facility’s corporate office on if the second POA document was valid as it was dated when R1 already had dementia. It was alleged that the facility staff does not allow R1 to have a voice in memory care because R1 sits with the same person during meals every day and R1 does not even like the person he/she sits with. It was alleged that the staff does not listen to R1 because R1 has Dementia. Based on staff interview, R1 did not have a preference of who he/she wanted to eat with. R1 would agree with whoever family member is in the room. R1 did not verbalize that he/she wanted to sit with certain residents or staff during mealtime. The Department has investigated the above allegations. Based on interview and record review, the above allegations are unfounded meaning the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with General Manager Billy Mitchell and a copy of the report was provided.